Seeding of osteosarcoma in the biopsy tract of a patient with multifocal osteosarcoma

Diagnostic yield and concordance of image-guided biopsy in musculoskeletal lesions

OBJECTIVE

Image-guided biopsy is well-established in the diagnosis of musculoskeletal lesions. While several studies have demonstrated a high diagnostic yield in image-guided biopsy, there are no current guidelines around procedural factors such as number of cores. Furthermore, there have been mixed results regarding which lesions are more favourable to a diagnostic biopsy. We wanted to evaluate diagnostic yield and concordance for image-guided biopsies for musculoskeletal lesions. The null hypothesis was that there are no controllable factors that contribute to positive yield.

MATERIALS AND METHODS

Retrospective review of consecutive patients who underwent image-guided biopsy at a large teaching hospital for musculoskeletal lesions discussed at the sarcoma multi-disciplinary meeting. The formal biopsy histology report was evaluated, and biopsies were considered diagnostic or non-diagnostic. In those that had subsequent surgery (by wide excision or open biopsy), final and initial histology was compared and biopsies were considered concordant or not. Overall diagnostic yield and concordance were calculated. Statistical analysis was performed with Stata 13.0 (StataCorp).

RESULTS

Over the 14-year period, 429 biopsies were included. Diagnostic yield was 85% and concordance was 100%. No cases of malignant lesions were initially called benign on biopsy. One biopsy had a complication (0.2%). Factors associated with higher diagnostic yield included soft tissue versus bone lesions, three or more cores and longer total specimen length. Factors that were not associated included core size, use of FNA cytology, gender, age, benign versus malignant, anatomic location and lesion appearance.

CONCLUSION

The null hypothesis is rejected. The main predictor of diagnostic biopsy was total specimen length, independent of number of cores taken. Three or more cores and longer cores are optimal, though these factors are influenced by lesion biology and not always able to be controlled.

Management of pelvic sarcoma

Pelvic sarcomas are a rare and heterogenous group of tumors divided into two groups: soft tissue sarcomas and bone sarcomas. Soft tissue sarcomas of the pelvis include most commonly liposarcoma, leiomyosarcoma, gastrointestinal stromal tumors, malignant peripheral nerve sheath tumors, and solitary fibrous tumors. Bone sarcomas of the pelvis most commonly include osteosarcoma and chondrosarcoma. Multidisciplinary treatment at a center experienced in the treatment of sarcoma is essential. Management is dictated by histologic type and grade. Surgical resection with wide margins is the cornerstone of treatment for pelvic sarcomas, although this is often challenging due to anatomic constraints of the pelvis. Multimodal treatment is critical due to the high risk of local recurrence in the pelvis.

Percutaneous Image-guided Needle Biopsy of Musculoskeletal Tumors: Technical Tips

With recent advances in imaging technology, the frequency of detecting musculoskeletal lesions has also increased. Percutaneous image-guided needle biopsy is occasionally required for the diagnosis of such lesions. Moreover, in the era of personalized cancer care, chances in histopathological diagnosis and the importance of histopathological diagnosis by percutaneous needle biopsy are increasing. However, as percutaneous needle biopsy is not a common procedure for musculoskeletal lesions, careful planning and the application of adequate techniques such as hydrodissection and the trans-osseous approach are occasionally required. In this review, we have summarized the indications and techniques for percutaneous image-guided needle biopsy for musculoskeletal lesions, including lymphatic lesions.

The Risk of Tumor Contamination Associated With Thoracic Instrumentation in Patients With Osteosarcoma: 2 Case Reports and a Literature Review

Orthopedic surgeons are well aware of tumor contamination at the site of initial biopsy in osteosarcoma. However, tumor contamination in patients with osteosarcoma associated with thoracic instrumentation is not well described. The authors summarize 2 reported cases in addition to the 2 cases at their institution of this phenomenon. Knowledge of tumor contamination and preventative measures against tumor contamination is sparse in the literature, especially pertaining to patients with osteosarcoma undergoing thoracic instrumentation. In this report, the authors hope to increase awareness of these cases and suggest preventative measures to mitigate against tumor contamination in patients with osteosarcoma. The authors report that the median time between thoracic instrumentation and the visible detection of tumor migration to local sites was 5 months. They conclude that tumor contamination associated with thoracic instrumentation is characterized by patients with multiple sites of relapse and aggressive, fatal disease.

The tactics and technique of musculoskeletal biopsy

The treatment of musculoskeletal neoplasms and infection is usually based on an initial diagnostic biopsy.

Prior to biopsy, a hypothesis should be formed about the most likely diagnosis and a differential diagnosis. These deliberations should consider whether the lesion is a primary benign or malignant tumour, a metastasis, a haematological problem or an infection.

A tactical plan should be developed which evaluates the necessity, the risk, the approach and finally defines the technique of biopsy most likely to achieve a representative result in the clinical case.

In developing this technical approach, the pitfalls should be anticipated, i.e. inadequate sampling, difficulty of pathological interpretation and contamination.

The tactical approach should be developed in conjunction with a multi-disciplinary team together with appropriate pre-biopsy imaging.

Cite this article: EFORT Open Rev 2017;2:51–57. DOI: 10.1302/2058-5241.2.160065

Are Biopsy Tracts a Concern for Seeding and Local Recurrence in Sarcomas?

BACKGROUND

A biopsy is the final step in the diagnosis of sarcomas. Complete resection of the biopsy tract traditionally has been recommended in musculoskeletal oncology guidelines, as that tract is considered potentially seeded with tumor cells. However, to our knowledge, the frequency and implications of contamination of the biopsy tract-specifically with respect to the likelihood of local recurrence-and the factors that affect cell seeding are not well described.

QUESTIONS/PURPOSES

We asked: (1) How often are biopsy tracts contaminated with pathologically detectable tumor cells at the time of tumor resection? (2) What factors, in particular biopsy type (open versus percutaneous), are associated with tumoral seeding? (3) Is biopsy tract contamination associated with local recurrence?

METHODS

This is a retrospective study of a database with patient data collected from a single center between 2000 and 2013. We treated 221 patients with sarcomas. A total of 27 patients (12%) were excluded and 14 (6%) were lost to followup. One hundred eighty patients finally were included in the analysis who either had biopsies at our center (112) or biopsies at outside institutions (68). Of those performed at our center, 15 (13%) were open and 97 (87%) were percutaneous; of those at outside centers, those numbers were 47 (69%) and 21 (31%) respectively. Median followup was 40 months (range, 24-152 months). During the study period, we generally performed percutaneous biopsies as a standard practice for the diagnosis of bone and soft tissue sarcomas and open biopsies were done when the percutaneous procedure failed to provide a histologic characterization. The mean age of the population was 48 years (range, 7-87 years); 60% were male; 42% had bone sarcomas. Nineteen patients had preoperative radiotherapy and 56 had postoperative radiotherapy. Fifty-seven patients received neoadjuvant chemotherapy and 73 had adjuvant chemotherapy. We determined what proportion of biopsy tracts were contaminated by pathologic analysis of the biopsy tract specimen; during the period in question, our routine practice was to excise the biopsy tract whenever possible at the time of the definitive resection. Using the logistic regression test and Mantel-Haenszel test, we compared open with percutaneous biopsies in terms of the proportion of those that were contaminated at our site and for outside referral biopsies separately, because we do not assume the level of expertise was the same (our site is a referral tumor center). We compared the local recurrence-free survival between patients with and without contamination and between open and percutaneous biopsies using the Kaplan Meier test, again separating those performed at our site from those referred for purposes of this analysis.

RESULTS

Twenty-one of 180 biopsy tracts were contaminated (12%). Twenty of 62 (32%) of the open biopsies and one of 118 (0.8%) of the percutaneous core needle biopsies had cell seeding (odds ratio [OR], 56; 95% CI, 7-428; p < 0.001. One of 97 (1%) percutaneous biopsies performed in our center, and none of the 21 (0%) percutaneous biopsies performed in other centers had contaminated biopsy tracts (p = 0.047). Two of 15 (13%) open biopsies performed at our center and 18 of 41(38%) open biopsies performed at other centers had contaminated biopsy tracts (OR, 4; 95% CI, 1-7; p = 0.001). Four of 74 (5%) bone sarcomas and 18 of 106 (17%) soft tissue sarcomas had biopsy tract contamination (OR, 3; 95% CI, 1-10; p = 0.023). The local recurrence-free survival was longer for patients without contaminated tracts (mean, 107 months; 95% CI, 74-141 months) than for those with biopsy tract seeding (mean, 11 months; 95% CI, 1-20 months; p < 0.001).

CONCLUSIONS

Open biopsies were associated with an increased risk of tumoral seeding of the biopsy site, and tumoral seeding was associated with an increased risk of local recurrence. However, it is possible that other factors, such as increased complexity of the tumor or a difficult location, influenced the decision to obtain an open biopsy. Even so, based on these results, we believe that higher risk of local recurrence may be caused by an incomplete biopsy tract resection. In our opinion, the percutaneous biopsy with neoadjuvant or adjuvant therapy is the preferred method of biopsy at our center.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Percutaneous guided biopsy for diagnosing suspected primary malignant bone tumors in pediatric patients: a safe, accurate, and cost-saving procedure

BACKGROUND

Percutaneous biopsy is the reference diagnostic procedure for adult musculoskeletal tumors. Its place in pediatrics is controversial and open biopsy remains recommended.

OBJECTIVE

To assess diagnostic performance and feasibility of percutaneous biopsy performed on children and young adults for suspected malignant bone tumors.

MATERIALS AND METHODS

We conducted a 5-year retrospective study including patients ≤21 years who underwent a bone biopsy for a suspected malignant bone tumor. We assessed diagnostic yield (percentage of analyzable biopsies), accuracy (percentage of accurate diagnoses among all analyzable biopsies) and efficacy (percentage of accurate diagnoses among all biopsies), costs, anesthetic requirements and sample availability for biomedical research. Patients diagnosed with an open biopsy were used to compare diagnostic performances, anesthetic requirements and costs.

RESULTS

We included 90 percutaneous and 27 open biopsies in 117 patients. For percutaneous biopsy, diagnostic yield was 95.5% (95% confidence interval [CI] 88.8-98.7%), accuracy was 96.2% (95% CI 86.8-99.5%) and efficacy was 89.3% (95% CI 78.1-96.0%). There was no statistical difference with open biopsy (Fisher exact test, P > 0.05). Mean costs were reduced with percutaneous biopsy: €1,937 (standard deviation [SD] €2,408) versus €6,362 (SD €5,033; Mann-Whitney, P < 0.0001). Thirty-two of the 48 (67%) patients included in clinical trials and diagnosed with percutaneous biopsy had suitable samples for ancillary analyses.

CONCLUSION

Percutaneous biopsy is a valid alternative to open biopsy for diagnosing pediatric and young adult primary malignant bone tumors.

Utility of Examination of Biopsy Tracts in Osteosarcoma Resection Specimens

OBJECTIVES

To determine the utility and necessity of submitting tissue sections from the biopsy tracts of osteosarcoma resection specimens.

METHODS

The prevalence of residual tumor in representative sections of osteosarcoma biopsy tracts was assessed in a series of 97 osteosarcoma resection specimens.

RESULTS

No residual tumor cells were identified in 97 sampled biopsy tracts (0%; 95% confidence interval, 0%-2.5%).

CONCLUSIONS

Pathologists do not need to submit sections of resected biopsy tracts unless there is clinical or gross evidence that would warrant further examination.

Benign and malignant tumors of the foot and ankle

Pain and focal masses in the foot and ankle are frequently encountered and often initiate a workup including imaging. It is important to differentiate benign lesions from aggressive benign or malignant lesions. In this review, multiple examples of osseous and soft tissue tumors of the foot and ankle will be presented. Additionally, the compartmental anatomy of the foot and ankle will be discussed in terms of its relevance for percutaneous biopsy planning and eventual surgery. Finally, a general overview of the surgical management of benign, benign aggressive and malignant tumors of the foot and ankle will be discussed.

TUMOR CONTAMINATION IN THE BIOPSY PATH OF PRIMARY MALIGNANT BONE TUMORS

Objective: To study factors possibly associated with tumor contamination in the biopsy path of primary malignant bone tumors. Method: Thirty-five patients who underwent surgical treatment with diagnoses of osteosarcoma, Ewing's tumor and chondrosarcoma were studied retrospectively. The sample was analyzed to characterize the biopsy technique used, histological type of the tumor, neoadjuvant chemotherapy used, local recurrences and tumor contamination in the biopsy path. Results: Among the 35 patients studied, four cases of contamination occurred (11.43%): one from osteosarcoma, two from Ewing's tumor and one from chondrosarcoma. There was no association between the type of tumor and presence of tumor contamination in the biopsy path (p = 0.65). There was also no association between the presence of tumor contamination and the biopsy technique (p = 0.06). On the other hand, there were associations between the presence of tumor contamination and local recurrence (p = 0.01) and between tumor contamination and absence of neoadjuvant chemotherapy (p = 0.02). Conclusion: Tumor contamination in the biopsy path of primary malignant bone tumors was associated with local recurrence. On the other hand, the histological type of the tumor and the type of biopsy did not have an influence on tumor contamination. Neoadjuvant chemotherapy had a protective effect against this complication. Despite these findings, tumor contamination is a complication that should always be taken into consideration, and removal of the biopsy path is recommended in tumor resection surgery.

A case of benign periosteal chondroma seeding into humeral medullary bone via percutaneous needle biopsy tract

We report an occurrence of periosteal chondroma seeding into the medulla of humerus via percutaneous needle biopsy tract. To our knowledge, this is the first described case of benign cartilage tumour biopsy tract seeding in the literature. We discuss the clinical, radiological and histological features of periosteal chondroma, as well as the diagnostic challenges associated with distinguishing this entity from periosteal chondrosarcoma. Finally, we briefly discuss the safety of imaging-guided percutaneous needle biopsy and methods to minimize the risk of iatrogenic tumour seeding.

Neoplasm seeding in biopsy tract of the musculoskeletal system. A systematic review

To identify, through a systematic literature review, the characteristics of neoplasm seeding in biopsy performed on the musculoskeletal system. We performed a search on PubMed, MEDLINE, LILACS and SciELO from August to October 2010. We included articles that addressed the neoplasm seeding in biopsy performed on the musculoskeletal system. The search was limited to English, Spanish and Portuguese as publication languages, but it was not limited by year of publication. We retrieved 2858 articles, but only seven were selected based on inclusion and exclusion criteria. Other four papers were found in the references of selected articles, totalizing 11 articles that were used to perform this systematic review. Issues may be raised in the literature: age and gender don't seem to influence the occurrence of neoplasm seeding; without resection of the biopsy tract, the possibility of local recurrence is very real; the influence of the type of tumor in the occurrence of neoplasm seeding is uncertain; it is impossible to conclude whether the closed biopsy technique has a lower chance of neoplasm seeding; it is likely that adjuvant chemotherapy has a protective effect against neoplasm seeding; an unfavorable prognosis is expected according to neoplasm seeding results.

Prevention of contamination by biopsy needle track contamination using a novel adriamycin-loaded gelatin sponge

Background

The gold standard of tumor diagnosis is histological examination of a biopsy; however, there is concern that tumor cell dissemination along the needle track during percutaneous biopsy can cause local tumor relapse. We aimed to evaluate the value of an adriamycin (ADM)-loaded gelatin sponge in preventing tumor cell contamination along the biopsy needle track.

Methods

Data were obtained from 40 patients who were diagnosed by core needle biopsy as having osteosarcoma and who were followed up at our hospital between 2008 and 2011. Of the 40 patients, 20 had the needle biopsy tracks filled with ADM-loaded absorbable gelatin sponge immediately after the biopsy specimen was obtained, while the other 20 did not. All 40 patients underwent limb-salvage surgery, and specimens were obtained from the biopsy track for histopathologic examination of multiple sections.

Results

On histological examination, there was less tumor cell contamination along the biopsy tracks in the ADM group.

Conclusion

Use of ADM-loaded absorbable gelatin sponge may prevent tumor cell contamination of a biopsy track, and reduce the possibility of consequent tumor relapse.

Accuracy of CT-guided percutaneous core needle biopsy for assessment of pediatric musculoskeletal lesions

BACKGROUND

CT-guided percutaneous core needle biopsy has been shown in adults to be an effective diagnostic tool for a large number of musculoskeletal malignancies.

OBJECTIVE

To characterize our experience with CT-guided percutaneous core needle biopsy of pediatric bone lesions and determine its utility in diagnosing pediatric osseous lesions, in a population where such lesions are commonly benign.

MATERIALS AND METHODS

From 2000 to 2009, 61 children underwent 63 CT-guided percutaneous biopsies. Radiological, pathological and clinical records were reviewed.

RESULTS

Fourteen biopsies (22%) were performed on malignant lesions, while 49 biopsies (78%) were performed on benign lesions. Forty-nine of the 63 biopsies (78%) were adequate; these children underwent no further tissue sampling. Fourteen of the 63 biopsies (22%) were inadequate or non-conclusive. Of these patients, 12 underwent open biopsy. Retrospective analysis of percutaneous biopsies in these patients demonstrates that 9/12 provided clinically relevant information, and 4/12 patients received final diagnoses that confirmed initial core biopsy findings. No malignancies were diagnosed as benign on percutaneous biopsy. Overall, percutaneous core needle biopsy provided accurate diagnostic information in 84% (53/63) of biopsies.

CONCLUSION

Our results demonstrate that CT-guided percutaneous biopsy is safe and beneficial in children. This study supports the use of CT-guided percutaneous core needle biopsy for primary diagnosis of pediatric bone lesions.

Does the taking of biopsies affect the metastatic potential of tumours? A systematic review of reports on veterinary and human cases and animal models

Clinicians and pathologists are sporadically asked by owners whether the taking of tumour biopsies may affect the behaviour of the tumour, including its potential to metastasise. Unfortunately, systematic studies on this subject are unavailable in veterinary medicine, and the aim of this study was to estimate the risk of adverse effects of biopsy taking on tumour progression in animals. A systematic review of veterinary and human case reports and clinical studies as well as experimental animal models of biopsy-induced tumour metastasis was undertaken. There were only two veterinary case reports of needle tract metastases (NTM) following the taking of needle biopsies from urogenital and pulmonary tumours. Seventeen experimental studies found a high incidence of NTM but only a rat osteosarcoma and a hamster squamous carcinoma model showed an increased incidence of distant or regional metastases after incision or excision biopsy. In human medicine, the occurrence of NTM has been reported after the taking of biopsies from mesotheliomas (15%), melanomas (11%) and gall bladder tumours (11%), liver metastases of colon carcinomas (4%) and mammary carcinomas (4%) but an incidence of only <1% for all other tumours. Circulating tumour cells increased immediately after the taking of biopsies from human squamous cell, prostate, breast and hepatocellular carcinomas. Although no increased risk of biopsy-induced distant metastasis has been reported for any type of tumour, this is inconclusive due to a lack of non-biopsied control groups in human studies. Reports of biopsy-induced metastasis in animal tumours indicate that the taking of transcutaneous biopsies from urogenital tumours may be associated with a risk of NTM. However, there is no evidence of a general increase in risk of distant metastases in any tumour type in people or animals. The overall risk therefore appears to be negligible when compared to the valuable information obtained from biopsies in veterinary practice.

Surgical management of primary osteosarcoma

Surgical strategies for the primary tumor for patients with extremity and pelvis osteosarcoma have evolved from the ablative to limb-sparing approaches over the past three decades. Favorable oncologic and functional outcomes with contemporary tissue-conserving techniques consistently observed in skeletally mature patients have prompted the application of similar approaches to a growing number of eligible skeletally immature patients. In response to emerging long-term outcome data, current strategies have focused principally on refining the nature and scope of surgical resection to preserve uninvolved tissues, and on the adoption of novel biological and nonbiological skeletal and soft-tissue reconstruction methods to optimize function. We focus on these clinical issues and discuss current efforts to advance the surgical management of the primary tumor and address the limitations of the definitive treatment of the primary tumor, including locally recurrent disease and complications of skeletal reconstructions.